Section 140.402  Copayments for Noninstitutional Medical Services

a)         Effective July 1, 2003 , each recipient, with the exception of those classes of recipients identified in subsection (d) of this Section, may be required to pay the following specified copayment for noninstitutional medical services:

1)         Each office visit to a chiropractor, podiatrist, optometrist, or a physician licensed to practice medicine in all its branches billed to the Department, with the exception of those office visits for services identified in subsection (e) of this Section, may require a copayment of $2.00.

2)         Each brand name legend drug billed to the Department, with the exception of drugs identified in subsection (e) of this Section, may require a copayment of $3.00.

b)         In each instance where a copayment is payable, the Department will reduce the amount payable to the affected provider by the respective amount of the required copayment.

c)         No provider of services listed in subsection (a) of this Section may deny service to an individual who is eligible for service on account of the individual's inability to pay the cost of a copayment.

d)         The following individuals receiving medical assistance are exempt from the copayment requirement set forth in subsection (a) of this Section:

1)         Pregnant women, including a  postpartum period of 60 days.

2)         Children under 19 years of age.

3)         All noninstitutionalized individuals whose care is subsidized by the Department of Children and Family Services or the Department of Corrections.

4)         Hospice patients.

5)         Individuals residing in hospitals, nursing facilities, and intermediate care facilities for the mentally retarded.

6)         Residents of a State-certified, State-licensed, or State-contracted residential care program where residents, as a condition of receiving care in that program, are required to pay all of their income, except an authorized protected amount for personal use, for the cost of their residential care program. For the purpose of this subsection (d)(6), the protected amount shall be no greater than the protected amount authorized for personal use under 89 Ill. Adm. Code 146.225(c).

e)         The following medical services are exempt from any copayments:

1)         Renal dialysis treatment.

2)         Radiation therapy.

3)         Cancer chemotherapy.

4)         Use of insulin.

5)         Services for which Medicare is the primary payer.

6)         Over-the-counter drugs.

7)         Emergency services as defined at 42 CFR 447.53(b)(4).

8)         Any pharmacy compounded drugs.

9)         Any prescription (legend drug) dispensed or administered by a hospital, clinic or physician.

10)         Family planning services.

11)         Other therapeutic drug classes as specified by the Department.

(Source:  Amended at 27 Ill. Reg. 18629, effective November 26, 2003)